Encyclopedia of

Compliance

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Definition

Compliance with appropriate, recommended, and prescribed mental health
treatments simply means that a person is following a doctor's
orders. Compliance is more likely when there is agreement and confidence
regarding the medical
diagnosis
and prognosis. Compliance is complicated by uncertainty about the nature
of an illness and/or the effects of certain treatments, particularly
medications.

In everyday usage, the term compliance means deference and obedience,
elevating the authority of medical expertise. Alternatively, adherence to
medical advice refers to a somewhat more informed and equitable decision
by a consumer to stick with appropriate medical treatment. In any case, a
mental health treatment cannot be effective or even evaluated if a
consumer does not follow a doctor's orders. A mental health
treatment that is effective for one disorder may not be beneficial for
other disorders, and diagnoses may evolve over time, complicating the
issue of compliance.

Health providers and consumers

From a health provider's viewpoint, in order for effective medical
treatments to have their desired effects, complying or conforming to
treatments is absolutely necessary. The concept of medication management
reflects this idea that the provider is responsible and in control, while
the consumer is a docile body who is incapacitated by disease or
condition. From the perspective of health consumers, adherence to medical
treatment is enhanced when there is a good health care relationship and
when consumers openly share their health beliefs and experience of illness
with their provider.

Problems with compliance

In mental health care, uncertainty about compliance is a challenging
source of variation in the effectiveness of treatments. Noncompliance can
represent a significant risk and cost to the medical system. For
providers, partial compliance or discontinuation of medications represents
the difficulty of maintaining treatment successes over time. Problems with
compliance are often attributed to the consumer, but may also reflect the
appropriateness of a medication or treatment.

Compliance rates

Rates of compliance with mental health appointments are the greatest
challenge (estimated in one hospital at 91%), while medication
noncompliance is the second most challenging problem in the treatment of
persons with mental illness. Mental health medication compliance can be
determined by questioning patients, counting pills or prescriptions, and
through drug monitoring with urine, blood, or other test measures.
Overall, recent research estimates compliance to be 58%. Patients who
report lower rates are often considered unreliable indicators of
compliance, while physicians report higher rates. Compliance with
antidepressant medications is higher on average (65%). Mental health
medication compliance rates are only somewhat lower than medication
compliance in other types of health care, which have been estimated at
76%.

Explaining variation in compliance

Research in psychiatry, psychology, and sociology provides many
explanations for variations in compliance. In psychiatry, clinical
problems such as drug or alcohol abuse are sometimes used to explain
noncompliance. Patients may also discontinue taking medications because of
unwanted side effects. Health beliefs and patient-provider relationships
are also recognized. In psychology and sociology, health beliefs and
behaviors (in context of family, work, etc.) may enhance or limit
compliance. If an individual's family member supports medication
compliance, and the individual believes in the medicine's benefits,
compliance may be enhanced. If an individual discontinues a medicine
because it makes him or her drowsy and affects work, compliance may be
reduced. People who have limited access to or trust in doctors or medical
science, and people whose faith precludes them from certain types of
medical care, are less likely to comply with treatment recommendations.

To a large extent, patient compliance is a direct reflection of the
quality of the doctor-patient relationship. When provider and consumer
achieve a successful treatment alliance, and when the treatment is
practical and beneficial for both the provider and the consumer,
cooperation reduces concerns about treatment for both parties. When
consumers are empowered and motivated to improve their health with the
help of a doctor, compliance or adherence to treatment is higher. When
there is distrust, disagreement, or misunderstanding involved, as when
mental health status is uncertain or treatment side effects are unwelcome,
compliance is lower. One British study found that patients with mental
disorders were likely to prefer the form of treatment recommended by
psychiatrists with whom they had good relationships, even if the treatment
itself was painful. Some patients preferred
electroconvulsive therapy
(ECT) to tranquilizers for depression because they had built up trusting
relationships with the doctors who used ECT, and perceived the doctors who
recommended medications as bullying and condescending. Since noncompliant
consumers are less likely to continue in care, they are also less likely
to find helpful providers or successful treatments. Thus, noncompliance
with treatment may become a self-fulfilling cycle.

Compliance is higher when treatments, including medications, help
consumers feel better, when a family supports the treatment, and when
taking medication prevents relapse of symptoms. However, as mentioned,
people may be distressed by potential side effects of any medication,
including those psychiatric medications that limit functioning. Limited
functioning through drowsiness, also a problem of the older generation of
antihistamines, is the best example. It is an effect of many medicines,
particularly those for mental disorders. Other unwelcome side effects of
various psychiatric medications include weight gain, involuntary movements
such as muscle twitching, and impaired coordination. Consumers may feel
embarrassed about taking medication, may have difficulty getting a
prescription for medication, and may have financial problems paying for
treatment or medication. In some cases, when a patient is non-compliant or
perceived to be at odds with treatment recommendations, they may risk
losing autonomy over medical decisions. When at risk to self or others,
people who are medication noncompliant may be pressured or forced to take
medication at the risk of being involuntarily hospitalized.

Multiple challenges in mental health care

Compliance rates reflect the proportion of individuals in treatment who
have the highest possibility of successful treatment. Noncompliance rates
reflect those individuals who have either discontinued or avoided
treatment, and thus have lower probabilities of treatment success.
Sometimes patients do not want to get rid of their symptoms (mania, for
example), or patients may not consider their experiences (called symptoms)
to be indicative of a disorder. In addition, successful mental health care
is hampered by the fact that many people with mental health problems
either do not use or lack access to mental health care.

The National Co-morbidity Survey shows that only 40% of individuals with
serious mental illness receive any treatment in a given year, and 39% of
this group receives minimally adequate care. This means that merely 15% of
all people in need receive minimally adequate care. Therefore, compliance
with treatment is part of a larger national challenge to provide quality
mental health care and to use it well.

Resources

BOOKS

Pescosolido, Bernice, Carol Boyer, and Keri Lubell. "The Social
Dynamics of Responding to Mental Health Problems."
Handbook for the Study of Mental Health,
edited by T. Scheid, and A. Horwitz. New York: Cambridge University Press.
1999.

Pescosolido, Bernice, and Carol Boyer. "How Do People Come to Use
Mental Health Services?"
Handbook of the Sociology of Mental Health,
edited by C. Aneshensel and J. Phelan. New York: Kluwer Academic, 1999.

PERIODICALS

Bebbington, P. E. "The Contend and Context of Compliance."
International Clinical Psychopharmacology
9, January 1995: 41-50.